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Data Chart for Tank System Tightness Test <br /> _ pEro Ti Le <br /> TANK TESTER <br /> 1. <br /> OWNER Properly <br /> l� e <br /> Tanks) <br /> Name 7 Adores. <br /> 2. <br /> OPERATOR �' �, .. -_ —_ .. <br /> �� Address — - _-—Telephone <br /> 3. REASON FOR TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED �._„ �,r�. /� 9 T7 <br /> TEST AND WHEN Name Title C.mpanyor Alflllalron Date <br /> _ t <br /> Telephone <br /> Address [ <br /> 6. WHO IS PAYING 3 ch+ ... c . GA Title Telephone — <br /> FOR THIS TEST? Company,Agency or Individual Person Aulhorlilnp — <br /> Billing Address City Slate Z'p <br /> Attention of Order No. Other Instructions <br /> 6. TANK(S) INVOLVED Identify by Direction Capacity trade Approx.Ape SteellFibarglaas <br /> ------------------------------------- <br /> 7, INSTALLATION Location Cover Fills veins Siphons Pumps <br /> DATA c�'� , AA-PEC g da G.. <br /> k$, <br /> Norlh inside driveway. 6oncrele.Black Top. Site Tilefill make.Drop Suclion,Remote, <br /> Rear of station.etc. Earth,etc. tubes.Remote HIS Site. Manilolded Which tanks' Make II known. <br /> alma wafer over the lank? <br /> 8. UNDERGROUND !Z <br /> WATER Depth to water table if known ❑ Yes No C <br /> 9. FILL-UP a b7 -- <br /> Tankstobefilietl _ �� — Date Arranged by __ _.. –_ - ---- - <br /> AflRANGEMENTS Name Telepnone <br /> Hour <br /> 10, TECHNICIANS <br /> 11, OTHER _ <br /> INFORMATION <br /> OR REMARKS -- --- <br /> f. <br /> Additional Information on any Items above.Officials or others to be adyised when testing is in progress or completed.visitors or observem present f <br /> a <br /> during test,eta C <br /> Teats were made on the above lank system$In,...formes with test procedures prescribed for petroTite <br /> TEST RESULTS al py <br /> $, as a on attached lest Charlie with results e*fell..,: hAfd1 a <br /> Tank Identification Tight Within Tolerance Out of Tolerance Date Testedall L <br /> � 7 <br /> rl: <br /> This 1$to certify that these lank systems were tested on the data(*)shown.Those Indicated as"Tight"meet the aherla established by the National Fire <br /> 13. CERTIFICATION <br /> Protection A$*.clsllon Pamphlet 729. <br /> Nama I ,,,on cortliylng <br /> To g Con for or Company. <br /> tc e�-wm. _—- Aaaress <br /> i1 No,tell tm—Ta �Jensdr <br />